Healthcare Provider Details

I. General information

NPI: 1861620213
Provider Name (Legal Business Name): ADAM W. GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 SE 14TH ST
BENTONVILLE AR
72712-4900
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 479-986-6199
  • Fax: 479-636-0371
Mailing address:
  • Phone: 314-543-6979
  • Fax: 314-364-6321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberE-8330
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberE-8330
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: